Gino Rigotti

Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells.

Background: There is evidence that stem cells contribute to the restoration of tissue vascularization and organ function. The objective of this study was to assess the presence of adipose-derived adult stem cells left in their natural scaffold in the purified lipoaspirate and to assess the clinical effectiveness of lipoaspirate transplantation in the treatment of radiation side effects. Methods: This study was designed beginning with surgical procedures in 2002 and envisaging a continuous patient follow-up to 31 months. Twenty consecutive patients undergoing therapy for side effects of radiation treatment with severe symptoms or irreversible function damage (LENT-SOMA scale grade 3 and 4) were enrolled. Purified autologous lipoaspirates (60 to 120 cc) taken from a healthy donor site were administered by repeated low-invasive computer-assisted injection. Therapy outcomes were assessed by symptoms classification according to the LENT-SOMA scale, cytofluorimetric characterization, and ultrastructural evaluation of targeted tissue. Results: In the isolated stromal vascular fraction of 2 cc of human lipoaspirate, cells with mesenchymal stem cell physical properties and immunophenotype were in average 1.07 ± 0.5 percent (n = 4), with a clonogenic fraction of 0.139 percent. At least 1.02 × 103 colony-forming units–fibroblast were present in each lipoaspirate. Ultrastructure of target tissue systematically exhibited progressive regeneration, including neovessel formation and improved hydration. Clinical outcomes led to a systematic improvement or remission of symptoms in all evaluated patients, including otherwise untreatable patients exhibiting initial irreversible functional damage. Conclusions: This surgical procedure is a low-invasive therapeutic approach for resolving the late side effects of radiotherapy. According to the proposed hypothesis of the ischemic nature of radiolesions, treatment with lipoaspirate transplantation is potentially extended to other forms of microangiopathies.

Obesity and Inflammation: Evidence for an Elementary Lesion

In obesity, an inflammatory process of the adipose tissue has been hypothesized; however, direct evidence for a tissue lesion is still lacking. Macrophage infiltration in the adipose tissue of obese individuals seems to be proven, but other alterations of the tissue have not been demonstrated. Moreover, in humans it has not been clarified whether inflammation is an early characteristic of obesity, because no data from obese children are available. In the present study, we assessed the inflammatory involvement of the adipose tissue and identified the elementary “inflammatory” lesion in a group of obese children. The study of children gives us the chance to investigate adipose tissue during early phases of obesity. In all the obese subjects, ultramicroscopic analysis of the adipose tissue demonstrated inflammatory involvement, and the extent of the lesions seemed to depend on the SD score of body mass index. The elementary lesion is a microgranuloma, with fragments of adipocytes, that evolves to fibrosis. Macrophages (and less frequently, lymphocytes or granulocytes) were found in perivascular positions. The lesions were not found in nonobese children. Our study proved that an “inflammatory” process exists in the adipose tissue of obese children, confirming previous findings in animals and obese adults and demonstrating that it is an early alteration in humans. However, the accumulation of macrophages was just one of the components of the inflammatory lesion, which also involved adipocyte degeneration, fibrosis, and, to a lesser extent, granulocyte/lymphocyte accumulation. The finding of fragments of adipocytes in the elementary lesion suggests that, at the beginning of the process, adipocytes may degenerate and that the materials generated by this process can recruit macrophages and other leukocytes. These preliminary results suggest that additional studies should be designed to clarify the cause of adipocyte fragility in obese children.

Subcutaneous adipose tissue classification.

The developments in the technologies based on the use of autologous adipose tissue attracted attention to minor depots as possible sampling areas. Some of those depots have never been studied in detail. The present study was performed on subcutaneous adipose depots sampled in different areas with the aim of explaining their morphology, particularly as far as regards stem niches. The results demonstrated that three different types of white adipose tissue (WAT) can be differentiated on the basis of structural and ultrastructural features: deposit WAT (dWAT), structural WAT (sWAT) and fibrous WAT (fWAT). dWAT can be found essentially in large fatty depots in the abdominal area (periumbilical). In the dWAT, cells are tightly packed and linked by a weak net of isolated collagen fibers. Collagenic components are very poor, cells are large and few blood vessels are present. The deep portion appears more fibrous then the superficial one. The microcirculation is formed by thin walled capillaries with rare stem niches. Reinforcement pericyte elements are rarely evident. The sWAT is more stromal; it is located in some areas in the limbs and in the hips. The stroma is fairly well represented, with a good vascularity and adequate staminality. Cells are wrapped by a basket of collagen fibers. The fatty depots of the knees and of the trochanteric areas have quite loose meshes. The fWAT has a noteworthy fibrous component and can be found in areas where a severe mechanic stress occurs. Adipocytes have an individual thick fibrous shell. In conclusion, the present study demonstrates evident differences among subcutaneous WAT deposits, thus suggesting that in regenerative procedures based on autologous adipose tissues the sampling area should not be randomly chosen, but it should be oriented by evidence based evaluations. The structural peculiarities of the sWAT, and particularly of its microcirculation, suggest that it could represent a privileged source for regenerative procedures based on autologous adipose tissues.

Adipose-Derived Mesenchymal Stem Cells: Past, Present, and Future

It is likely that in the future, the past decade in the historyof plastic surgery will be remembered for the introductionof reconstructive therapies based on the use of stem cells.Of the variety of different approaches that have been pro-posed, those that have been most widely used in recentyears, and which therefore seem most promising for thefuture, are those using adipose-derived mesenchymal stemcells [1]. The current use and the immense promise of stemcells from adipose tissue are due largely to three aspectsthat make the procedure simple:1. The possibility of minimally invasive autologoustransplants. Adipose-derived mesenchymal stem cellsare obtained by lipoaspiration followed by centrifuga-tion. They can be directly injected into areas to betreated immediately after extraction, there in theoperating theatre.2. Cell expansion is not necessary. As said, the cells canbe injected immediately after extraction, along withthe lipoaspirate that surrounds them. They do not needto be pre-expanded in vitro. To complete the concept,the addition of the lipoaspirate means that what areinjected are ‘‘stem cell niches’’ in which the cells aresurrounded by a glycoproteic scaffold, including tissuefactors that would be eliminated with digestion of thematrix if treated with collagenase—an indispensablestep if expansion in vitro were necessary.3. Age is no barrier. The procedure can be carried out atany time in a patient’s life since adipose stem cells areabundant even in the elderly and show the ability torepair lesionated tissues highly efficiently.The efficacy of the technique has been confirmedrepeatedly and under a variety of different conditions. Howdid this use of adipose-derived mesenchymal stem cellsoriginate and develop? And above all, what are the futuretherapeutic possibilities of this technique?The Past: Fat as a FillerAt times, medical research originates from old ideas thatwere not sufficiently investigated or interpreted in the past.What we are discussing is a good example: The idea ofautologous transplants of fatty tissue is not new in plasticsurgery. There are publications about the use of fat as afiller that date back to the end of 19th century. The tech-nique of ‘‘lipofilling’’ developed out of these experiencesand has been used to treat thousands of patients with a widerange of indications. However, despite its undoubtedadvantages, the simple injection of fat was not withoutproblems, the most significant being the poor reproduc-ibility of results and the risk of generating ‘‘nodules,’’which can lead to oil cysts or, less frequently, to granulo-mas. Credit is due to Coleman for directing attention tothese limitations, which were linked to the techniques usedto extract and inject fat, and for laying the foundations for amore effective use of adipose tissue [2]. His main insightwas to understand the importance of a uniform distributionof the lipoaspirate injected into the tissue to be treated,

Tissue-engineered breast reconstruction with Brava-assisted fat grafting: a 7-year, 488-patient, multicenter experience.

Background: The ability of autologous fat transfer to reconstruct an entire breast is not established. The authors harnessed the regenerative capabilities of external expansion and autologous fat transfer to completely reconstruct breasts. Methods: The authors performed 1877 Brava plus autologous fat transfer procedures on 616 breasts in 488 women to reconstruct 99 lumpectomies, 87 immediate breast reconstructions, and 430 delayed total breast reconstructions. After 2 to 4 weeks of Brava expansion, which increased volume by 100 to 300 percent, the authors diffusely grafted the breasts with 100 to 400 ml (225 ml average) of 15 g–sedimented, manually harvested lipoaspirate. The procedure was repeated every 8 to 14 weeks until completion. The authors compared costs of this reconstruction with established deep inferior epigastric artery perforator/transverse rectus abdominis musculocutaneous flaps and implant procedures. Results: Follow-up ranged from 6 months to 7 years (mean, 2.5 years), with 0.5 percent locoregional recurrence. Four hundred twenty-seven women completed the reconstruction, whereas 12.5 percent dropped out (2.5 percent medical, 10 percent personal reasons). Completion required 2.7 procedures for nonirradiated and 4.8 procedures for irradiated mastectomies. Patients recovered soft, natural appearing breasts with nearly normal sensation. Complications included five pneumothoraces and 20 ulcerative infections. Radiographically recognized benign palpable masses were observed in 12 percent of nonirradiated and 37 percent of irradiated breasts. The cost of Brava plus autologous fat transfer is 47 percent and 66 percent that of current reconstruction alternatives. Conclusion: Brava plus autologous fat transfer is a minimally invasive, incisionless, safe, economic, and effective alternative for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Megavolume autologous fat transfer: part II. Practice and techniques.

The authors describe the techniques that use the principles of fat grafting to allow them to successfully graft megavolumes (250-ml range) of autologous fat into breasts. The Brava external volume expansion device preoperatively increases the volume and vascularity of the recipient site. Low-pressure liposuction and minimal centrifugation are used to gently extract and purify the adipose tissue with minimal trauma. Even and diffuse reinjection of the fat increases graft-to-recipient interface and reduces interstitial fluid pressure. Postoperative Brava use protects the graft and acts as a three-dimensional immobilizing splint. By adhering to these techniques, we have been able to graft megavolumes of fat into the breasts of over 1000 patients and obtain substantial long-term volume retention.

Percutaneous aponeurotomy and lipofilling: a regenerative alternative to flap reconstruction?

Background: The application of a new approach is presented, percutaneous aponeurotomy and lipofilling, which is a minimally invasive, incisionless alternative to traditional flap reconstructions. Methods: The restrictive subdermal cicatrix and/or endogenous aponeurosis is punctured, producing staggered nicks. Expansion of the restriction reconstructs the defect and creates a vascularized scaffold with micro-openings that are seeded with lipografts. Wide subcutaneous cuts that lead to macrocavities and subsequent graft failure are avoided. Postoperatively, a splint to hold open the neomatrix/graft construct in its expansive state is applied until the grafts mature. Thirty-one patients underwent one to three operations (average, two) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (n = 9), contour defects of the trunk and breast requiring large-volume fat grafts (n = 8), burn contractures (n = 5), radiation scars (n = 6), and congenital constriction bands (n = 3). Results: The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range, 20 to 30 percent). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion. Conclusions: Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its three-dimensional expansion, a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts was developed. Grafting this scaffold applies tissue-engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells.

Background: The regenerative property of fat grafting has been described. However, it is not clear whether the clinical results are attributable to the stem cells or are linked to other components of the adipose tissue. This work is aimed at analysis of the histologic and ultrastructural changes of aged facial skin after injection of fat graft in addition to its stromal vascular fraction, obtained by centrifugation, and to compare the results with those obtained by the injection of expanded adipose-derived mesenchymal stem cells. Methods: This study was performed in six consecutive patients who were candidates for face lift and whose ages ranged between 45 and 65 years. The patients underwent sampling of fat by liposuction from the abdominal region. The injection of fat and its stromal vascular fraction or expanded mesenchymal stem cells was performed in the preauricular areas. Fragments of skin were removed before and 3 months after each treatment and analyzed by optical and electron microscopy. Results: After treatment with the autologous lipidic component and stromal vascular fraction, the skin showed a decrease in elastic fiber network (elastosis) and the appearance of new oxytalan elastic fibers in papillary dermis. The ultrastructural examination showed a modified tridimensional architecture of the reticular dermis and the presence of a richer microvascular bed. Similar results following treatment with expanded mesenchymal stem cells were observed. Conclusion: This study demonstrates that treatment with either fat and stromal vascular fraction or expanded mesenchymal stem cells modifies the pattern of the dermis, representing a skin rejuvenation effect.

Expanded Stem Cells, Stromal-Vascular Fraction, and Platelet-Rich Plasma Enriched Fat: Comparing Results of Different Facial Rejuvenation Approaches in a Clinical Trial.

BACKGROUND In a previous study, the authors demonstrated that treatment with expanded adipose-derived stem cells or stromal vascular fraction (SVF)-enriched fat modify the pattern of the dermis in human beings, representing a skin rejuvenation effect. Considering that expanded stem cells require a cell factor, the authors wanted to assess similar results by replacing them with platelet-rich plasma (PRP), which is easier to obtain and for which an empirical regenerative effect has been already described. OBJECTIVES To determine if PRP injection could replace the cutaneous regenerative effect of adipose-derived stem cells. METHODS This study was performed in 13 patients who were candidates for facelift. The patients underwent sampling of fat by liposuction from the abdomen and submitted to one of three protocols: injection of SVF-enriched fat or expanded adipose-derived stem cells or fat plus PRP in the preauricular areas. Fragments of skin were removed before and 3 months after treatment and analyzed by optical and electron microscopy. RESULTS The use of fat plus PRP led to the presence of more pronounced inflammatory infiltrates and a greater vascular reactivity, increasing in vascular permeability and a certain reactivity of the nervous component. The addition of PRP did not improve the regenerative effect. CONCLUSION The use of PRP did not have significant advantages in skin rejuvenation over the use of expanded adipose-derived stem cells or SVF-enriched fat. The effect of increased vascular reactivity may be useful in pathological situations in which an intense angiogenesis is desirable, such as tissular ischemia.

Autologous fat grafting in breast cancer patients

In the frame of the debate on the oncological safety of autologous fat grafting in breast reconstruction, we comment on the Personal View article recently appeared on The Breast by Lohsiriwat and colleagues (Breast 2011; 20:351–357), which reports a literature analysis, questioning the safety of fat grafting in patients with breast cancer. When mentioning the work by Rigotti et al. (Aesth Plast Surg 2010; 34:475), Authors claim that the methodology “should be criticized, because the risk of LRR (Late Relapse Rate) decreases with time and cannot be considered as equivalent in the pre and post lipofilling period”. This bias exists and was discussed for the dependent-group analysis reported in that paper; conversely, Authors lack mentioning that comparable relapse-free survival probabilities were found (log-rank test 1⁄4 1.69; p 1⁄4 0.19) in the frame of an independent–group analysis, designed to compare LRR in the period from surgery to first fat grafting session (Period I) in a group of patients, with LRR in the period starting from first fat grafting session, in average 20 months after surgery, of a second independent patient cohort. This result was confirmed (log-rank test 1⁄4 1.27; p 1⁄4 0.26) also when taking out from Period I the first 20 months after surgery, in order to avoid any possible bias on LR risk equivalence. In addition, Authors criticize the exclusion from the study of 104 breast conservative treatment patients, proving to have overlooked the reported patient inclusion criteria, according to which only 13 breast conservative treatment patients could have been